SjÖgrenSyndrome

WHAT IS SJÖGREN SYNDROME?Sjögren Syndrome (pronounced, show-gren) is an autoimmune disease characterized by malfunction of the tear and saliva producing glands and the mucous-secreting glands of the vagina. The result is the feeling of dryness of the eyes, mouth, and vagina. It may also lead to a variety of different body system abnormalities such as enlarged lymph nodes, neuropathy (inflammation of nerves leading to numbness and tingling) and joint pain. Sjögren Syndrome may be primary (occurring alone, not associated with other diseases) or secondary (occurring in patients who have another autoimmune disease such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma). Over 20% of scleroderma (systemic sclerosis) patients have Sjögren Syndrome, which occurs most commonly in those with limited skin thickening (old term CREST syndrome).

CAUSESSjögren Syndrome is caused by accumulation of a type of white blood cells (lymphocytes) in affected glands which leads to gland malfunction. Lymphocytes are normally found in the blood stream, lymph nodes, spleen, and bone marrow. Their appearance in glandular tissues is abnormal, signifying that organization of the immune system has become faulty. The result is reduced production of tears, saliva, and vaginal secretions.

SYMPTOMSDry EyesYou may have a “gritty” or “sandy” feeling in your eyes. On awakening in the morning you may notice increased thick mucus in the corners of your eyes nearest your nose. Your eyes may be unusually sensitive to bright light (photophobia).

Dry MouthYou will produce less saliva, which makes moving food in your mouth and speaking more difficult, and reduces your sense of taste. You will crave water or other liquids. You may not be able to eat a dry cracker without water, or eat a meal without frequent sips of water. You may feel the need to take a bottle of water with you wherever you go. Your nose and throat may also be dry, leading to decreased sense of smell, nosebleeds, hoarseness, and dry cough. Your major

saliva producing glands (parotid glands, just below and in front of your ears) may become painlessly enlarged, giving the appearance of mumps.

Dry VaginaYou may experience vaginal irritation, making sexual intercourse uncomfortable.

(Caution to patients: There are many other causes of glandular dryness. Increased age, other diseases of the eyes and mouth, certain medications, and lack of estrogen in the vagina are common reasons for dryness which should be considered by your physicians.)

Other SymptomsYou may suffer from fatigue, which can be severe enough to interfere with your lifestyle. You may have stiffness or swelling of the small joints of your hands (arthritis) and other joints. Joint pain and stiffness are typically worse in the morning and improve within one to two hours. Muscle pain or weakness can occur, leading to difficulty arising from a chair or lifting your arms over your head. You could experience white or blue color changes at the tips of your fingers during cold exposure (Raynaud phenomenon).

DIAGNOSISThe diagnosis of Sjögren Syndrome is based on the presence of suggestive symptoms in the medical history, physical examination, blood tests and occasionally, additional testing by your physician.

Eye TestsThe Schirmer test is a screening method to measure how much you are able to wet a strip of filter paper placed inside your lower eyelid. If the paper is wet less than 6 millimeters in five minutes after placement, it is considered a positive test by most experts. Reduced tearing should be confirmed by an ophthalmologist, who can perform additional more sophisticated tests and look for other causes of dry eye.

Mouth TestsSaliva can be collected in a cup in your doctor’s office over a 10 minute period of time; less than 2 tablespoons of saliva suggests reduced production. A biopsy of the inside of the lower lip may support the diagnosis. In Sjögren Syndrome, a greatly increased number of lymphocytes is seen surrounding the small saliva-producing glands located in the lip. Injection of

dye into the parotid duct (sialogram) can demonstrate characteristic enlargement (dilatation) and distortion of these ducts.

Laboratory TestsOnly half of Sjögren patients have anti-SSA and/or anti-SSB (Sjögren Syndrome A and B) antibodies in their blood. Other tests that may be abnormal include the white blood cell count (low), total gamma globulin level (high), blood C3 and C4 complement levels (low C4), sedimentation rate (high) and rheumatoid factor (positive).

COMPLICATIONSEyesEye dryness may cause dry spots or ulcers on the cornea, leading to inability to wear contact lenses and in some cases scarring with reduced vision. Affected eyes are more prone to viral and bacterial infections.

Mouth and SinusesAn increased number of cavities and infection of the gums (gingivitis) with loosening of the teeth may occur. There is an increased frequency of overgrowth of the common yeast candida, resulting in a mouth infection termed candidiasis (can-di-DYE-ah-sis) or “thrush.” There may be slow and painless enlargement of the parotid (mumps) glands due to blockage of the ducts through which saliva flows from the glands into the mouth. If rapid, painful enlargement of one of these glands occurs, accompanied by redness of the overlying skin and fever, this may indicate a secondary bacterial infection of the gland and is a medical emergency. When lymphocytes interfere with normal handling of infectious agents such as viruses and bacteria, sinus infections become more frequent.

Respiratory TractAgain, because lymphocytes invade normal tissues, there is an increased risk of developing infections such as bronchitis and pneumonia. The lung tissue itself may be the site of lymphocyte accumulation, leading to shortness of breath and an abnormal chest X-ray (interstitial fibrosis), but this is uncommon.

Nervous System Lymphocytes or their products may directly injure nerves in the brain, spinal cord, or extremities. The results can be disturbances of memory and thought processes, weakness, and abnormal sensation in the lower extremities, bowel and bladder dysfunction, and numbness, tingling, “pins and needles” or burning sensation of the toes and feet. These problems may be permanent since the ability of nerves to regenerate is limited.

VasculitisA few patients develop vasculitis (inflammation of the walls of small blood vessels). A red spotted rash on the legs and numbness and tingling of the feet and toes are clues to this complication. Vasculitis can also affect internal organs such as the heart and intestinal tract and is a serious complication.

KidneySome patients with Sjögren Syndrome develop blood and/or protein in the urine and, in rare cases, mild kidney malfunction. There are no urinary symptoms associated with these problems, and thus a periodic urinalysis and blood creatinine level should be checked. Excessive loss of potassium in the urine may lead to a low blood potassium level and muscle weakness.

SkinA characteristic rash may appear in skin areas exposed to ultraviolet light or sunlight (photosensitive rash). The rash is most often transient. It may be scaly or appear as circular or oval patches of red skin with a central white area.

PregnancyA woman with Sjögren Syndrome and anti-SSA antibody in her blood may pass this antibody across the placenta to her developing fetus. One result may be a transient lupus-like facial rash in the infant after delivery. A more serious problem is permanent injury

to the fetal heart, leading to a very slow heartbeat (heart block). This problem can occur as early as the third month of pregnancy and is often fatal. For these reasons, women with Sjögren Syndrome should consult their rheumatologist and obstetrician before attempting to become pregnant.

LymphomaRarely, the lymphocytes in Sjögren patients can become malignant, resulting in lymphoma. This complication affects approximately 5% of primary Sjögren Syndrome patients and is somewhat less common in Sjögren Syndrome patients with secondary systemic sclerosis and typically occurs in those who have had the disease for many years. Patients may complain about excessive fatigue and are found to have multiple painless enlarged lymph nodes or unusually rapid painless enlargement of a parotid gland. The diagnosis is made by lymph node or parotid gland biopsy. Fortunately, most lymphomas in Sjögren Syndrome patients respond well to chemotherapy.

TREATMENTThere is no recognized cure for Sjögren Syndrome. Therefore, doctors try to treat the symptoms of the disease to minimize their effects on your daily life. The following aids may be recommended:

For dry eyes• Artificial tears (preservative free), up to once an

hour, or a long-acting pellet in the morning and a lubricating ointment at night

• Punctal occlusion, a surgical procedure to retain moisture by preventing the normal flow of tears from the inner corner of the eye into the nose. This can be temporary (by inserting small plastic plugs) or permanent by tying off the ducts with a suture or burning the duct with a probe [cauterization].

For dry mouth• Sips of water throughout the day or over-the-

counter saliva substitutes or gels• Sugar-free chewing gum or candies to stimulate

saliva flow• Treatment for oral candidiasis• One of several oral saliva stimulant medications

containing the active ingredient pilocarpine• Good oral hygiene to prevent cavities: frequent

dentist visits for teeth cleaning; brushing and flossing teeth regularly and thoroughly, especially after meals; avoiding sugar-containing foods and drinks between meals; using mouth rinses containing fluoride

• Several saliva stimulating medications (pilocarpine and Evoxac®) are available as prescription drugs.

For vaginal dryness• Specially designed lubricants, but do not use

petroleum jelly (does not moisturize the vaginal lining)

For other organs affected• Common-sense measures: avoid cigarette smoking;

pace activities to avoid fatigue; get adequate exercise and sleep

• Aspirin or anti-inflammatory drugs for joint pain and stiffness or muscle pain

• Hydroxychloroquine (Plaquenil®) for arthritis, skin rash, fatigue, etc.

• Cortisone or immune system suppressing drugs for more serious problems such as involvement of the lung, kidney, nervous system, or vasculitis

HOW IS SJÖGREN SYNDROME RELATED TO SCLERODERMA?Over 20 percent of patients with systemic sclerosis and a few with localized scleroderma also have Sjögren Syndrome. It is more often detected in persons with the limited form of systemic sclerosis. The symptoms and examination findings and methods of diagnosis and treatment in Sjögren Syndrome in scleroderma patients are identical to those in primary Sjögren Syndrome. Special problems encountered by scleroderma patients are reduced mouth opening, finger-tip ulcers, and deformities of the fingers, all of which interfere with maintaining good oral hygiene. Therefore it is particularly important for scleroderma patients to consult their dentists and periodontists to make sure they use appropriate measures to maximize oral hygiene.

The Scleroderma Foundation thanks Thomas A. Medsger, Jr., M.D., Professor of Medicine Emeritus, University of Pittsburgh, for his help in preparing this brochure.

Disclaimer: The information provided is for educational purposes only. Any drugs or treatments mentioned should be discussed with your own physician(s).

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Funding for this brochure was provided by an unrestricted educational grant from Actelion Pharmaceuticals USA, Inc.